When to Invasively Measure Pressures in HFpEF?Kavita Sharma, MDAssistant Professor of MedicineInterim Director, Advanced Heart Failure & Transplant Cardiology SectionDirector, JHU HFpEF ProgramApril 18, 2020 1

When to Invasively Measure Pressures in HFpEF?Kavita Sharma, MDAssistant Professor of MedicineInterim Director, Advanced Heart Failure & Transplant Cardiology SectionDirector, JHU HFpEF ProgramApril 18, 2020 1 DisclosuresFunding Support: •AHA Go Red for Women SFRN (16SFRN27870000)•AHA SFRN SoterCollaborative grant•JHU Clinician Scientist Award•MyokardiaAdvisory/Consulting: •Novartis, J&J 2 Objectives•Patient Case •HFpEF Definitions•Evolving Demographics of HFpEF•Hemodynamics testing in HFpEF•Summary 3 HFpEF Epidemiology: Rising Prevalence 4 OktayAA, Rich JD, Shah SJ. CurrHeart Fail Rep 2013 Patient F.S. •61 yoF referred to JHU HFpEF Clinic•PMH: HTN, obesity, OSA, pre-DM•HPI: –2 years of progressive dyspnea with walking–2 pillow orthopnea–bendopnea –occasional PND Exam •BMI 40.1•BP 150/70, HR 75•Obese, AA Female•Labored breathing getting up on exam table•JVP 10, positive HJR•Lungs clear•S1/S2, no murmurs, no gallops•Minimal non-pitting edema of legs Patient Case: Studies•Na 143, K 4.4 •Creat1.4•Hgb14.6•TSH 1.50•HgbA1c 6.2•Trop-I negative•NT-proBNP 32•EKG: NSR, HR 70 •Echocardiogram:–EF 75%–LVDD 4.21–IVSd1.5 cm–LA diam3.7 cm–E/e’8.6–“normal diastolic filling pattern for age”–normal RV size Next Steps? •Is this HFpEF? •Empirically treat? •Is more testing needed…?YES! ACC/AHA 2013 Definition Yancyet al. 2013 Circulation. 62:e147-239 ESC 2016 Definition PonikowskiP, et al. EHJ 2016;37:2129-200 In the real world… JHU HFpEF Clinic•LVEF ≥ 50% and•Signs and symptoms of CHF and •Objective evidence of a cardiac problem–Elevated BNP or–Structural heart disease (LAE, LVH, DD) or–Elevated PAWP (≥ 15 mmHg) or –Elevated LV end-diastolic pressure (≥ 15 mmHg)•Additional: Rise in PAWP with exercise to ≥ 20-25 mmHg Patient Case: Exercise RHC •Baseline: –RA 8–PA 23/13 (16)–PAWP 11–PA sat 66.7%–CO 4.63 / CI 1.97–PVR 1.08 •Peak exercise, 35W–RA 21–PA 45/28 (34)–PAWP 25–PA sat 54%,–CO 10.3 / CI 4.38–PVR 0.58 Supine bicycle exercise test Diagnosis: Exercise-induced HFpEF Patient Case: Treatment •Blood pressure management•Initiated on Spironolactone•Low-dose diuretic •Exercise program•Screened for clinical trial enrollment Evolving Demographics in HFpEFROPA-DOPCohortTotal(n=90)Age, years66 (13)Female, (%)61AA, (%) 56HTN, (%)85Diabetes, (%) 53A Fib, (%)32BMI40.8eGFR58NTpro-BNP, pg/mL2132 Sharma K, et al. JACC-HF 2018;6:859–70; KitzmanD, Shah S JACC 2016;68:200-203 Hemodynamics in Real World Practice HFpEF (91)Invasive HemodynamicsRA (mmHg)10PASP(mmHg)44PADP (mmHg)20mPAPressure (mmHg)29PCWP (mmHg)18CO, thermodilution(L/min)5.73CI, thermodilution(L/min/m2)2.50BiomarkersNT-proBNP(pg/mL)3126 minute walk distance6MW Distance (m)201.3 Exercise Hemodynamics Borlaug et al. 2010 Circulation;3:588-595. •Patients with exertional dyspnea, EF > 50% were referred for RHC•Those with no significant CAD, normal NPs, and normal resting hemosunderwent exercise study. Phenotype-based Treatment Approach to HFpEF 17 Shah S, Paulus W et al. Circulation 2016 Take Home Messages –When to use hemodynamic testing in HFpEF? •Routinely! This is the gold standard test for HFpEF diagnosis. •Echo and NP often are not enough. •Consider exercise hemosin those with normal resting numbers, on diuretic therapy, symptoms out of proportion to exam/ RHC, to evaluate for concomitant PAH.•Clinical trial enrollment, targeted therapeutics. THANK YOU!ksharma8@jhmi.edu 19